| East Texas Dental Group, Llc | |
|
212 Old Grande Blvd B224 Tyler TX 75703-4226 | |
| (903) 509-0505 | |
| (903) 509-0506 |
| Full Name | East Texas Dental Group, Llc |
|---|---|
| Speciality | Dentist |
| Location | 212 Old Grande Blvd, Tyler, Texas |
| Authorized Official Name and Position | Young T Shim (OWNER) |
| Authorized Official Contact | 9035090505 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| East Texas Dental Group, Llc 212 Old Grande Blvd Suite B224 Tyler TX 75703-4226 Ph: (903) 509-0505 | East Texas Dental Group, Llc 212 Old Grande Blvd B224 Tyler TX 75703-4226 Ph: (903) 509-0505 |
| NPI Number | 1750743167 |
|---|---|
| Provider Enumeration Date | 03/24/2016 |
| Last Update Date | 03/24/2016 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1750743167 | NPI | - | NPPES |
| 352003301 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 31033 (Texas) | Primary |
Kim Fretty Orthodontics Pllc Dental Clinic Medicare: Not Enrolled in Medicare Practice Location: 6989 Highlands Ln, Tyler, TX 75703 Phone: 903-561-7873 | |
Pediatric Dentistry Of Tyler, Pllc Dental Clinic Medicare: Not Enrolled in Medicare Practice Location: 3607 Old Jacksonville Rd, Tyler, TX 75701 Phone: 903-595-5476 | |